Use of organic compounds

ABSTRACT

This application is directed to methods for improving glucose control by administering metformin in combination with a DPP-IV inhibitor to a patient in need thereof, in an amount sufficient to control the glucose level over an extended period of time.

This application is a continuation of copending U.S. application Ser.No. 11/628,546, field Dec. 4, 2006, which is a 371 application ofPCT/EP2005/006003, filed on Jun. 3, 2005, which claims benefit under 35U.S.C. §119(e) of U.S. Provisional Application Nos. 60/577,010, filedJun. 4, 2004, and 60/604,273, filed Aug. 25, 2004, the contents of whichare incorporated by reference herein in their entirety.

The invention relates to a method of treatment and a diagnostic method,wherein the patient is treated with a Dipeptidyl peptidase IV inhibitor(DPP-IV inhibitor) or a pharmaceutically acceptable salt thereof andmetformin over an extended period of time preferably one year or more.

The treated patients are preferably suffering from hyperglycemia such asdiabetes mellitus preferably non-insulin-dependent diabetes mellitus orImpaired Glucose Metabolism (IGM) preferably Impaired Glucose Tolerance(IGT).

Diabetes mellitus is a relatively common disorder (estimated at about 1%prevalence in the general population) which is characterized byhyperglycemia. There are three basic types of diabetes mellitus, type Ior insulin-dependent diabetes mellitus (IDDM), type II ornon-insulin-dependent diabetes mellitus (NIDDM), and type A insulinresistance. Patients with either type I or type II diabetes can becomeinsensitive to the effects of exogenous insulin (“insulin resistant”)through a variety of mechanisms. Type A insulin resistance results fromeither mutations in the insulin receptor gene or defects inpost-receptor sites of action critical for glucose metabolism. Diabetesis generally controlled through administration of exogenous insulin(especially in type I diabetics), dietary control and exercise(especially in type II diabetics) or both.

Impaired Glucose Metabolism (IGM) is defined by blood glucose levelsthat are above the normal range but are not high enough to meet thediagnostic criteria for type 2 diabetes mellitus. The incidence of IGMvaries from country to country, but usually occurs 2-3 times morefrequently than overt diabetes. Until recently, individuals with IGMwere felt to be pre-diabetics, but data from several epidemiologicstudies argue that subjects with IGM are heterogeneous with respect totheir risk of diabetes and their risk of cardiovascular morbidity andmortality. The data suggest that subjects with IGM, in particular IGT,do not always develop diabetes, but whether they are diabetic or not,they are, nonetheless, at high risk for cardiovascular morbidity andmortality. Among subjects with IGM, about 58% have Impaired GlucoseTolerance (IGT), another 29% have Impaired Fasting Glucose (IFG), and13% have both abnormalities (IFG/IGT). IGT is characterized by elevatedpostprandial (post-meal) hyperglycemia while IFG has been defined by theADA (see Table below) on the basis of fasting glycemic values.

The categories of Normal Glucose Tolerance (NGT), IGM and type 2diabetes mellitus were defined by the ADA (American DiabetesAssociation) in 1997.

The fact that IGT is an independent risk factor in non-diabetics as wellas diabetics justifies it as a new indication, separate from diabetes,for prevention and treatment of cardiovascular morbidity and mortalityas well as cancer. Furthermore the stage between normoglycemia and type2 diabetes mellitus, especially the glycemic stage, is becoming of majorinterest and there is a strong need for a method to inhibit or delay theprogression to type 2 diabetes mellitus, and also the variety ofcardiovascular and microvascular conditions and diseases as well ascancer that have been associated with IGM and especially IFG and/or IGT.

Type 2 diabetes is a progressive disease, and although monotherapy mayinitially control blood glucose in some patients, it is associated witha high secondary failure rate. This high incidence of therapeuticfailure is a major contributor to the high rate of long-termhyperglycemia-associated complications in patients with type 2 diabetes.The limitations of single-agent therapy for maintaining glycemic controlmay be overcome, at least in some patients, and for a limited period oftime by combining multiple oral drugs to achieve reductions in bloodglucose that cannot be sustained during long-term therapy with singleagents. Available data support the conclusion that in most patients withtype 2 diabetes, oral monotherapy will fail and treatment with multipledrugs will be required.

But, because Type 2 diabetes is a progressive disease, even patientswith good initial responses to combination therapy will eventuallyrequire an increase of the dosage or further treatment with insulinbecause the blood glucose level is very difficult to maintain stable fora long period of time.

Although combination therapy has the potential to enhance glycemiccontrol, it is not without limitations. Many results indicate that therisk for hypoglycemia may increase with combination therapy, and therequirement for multiple medications may also reduce patient compliance.In addition, taking multiple antihyperglycemic drugs increases thepotential for pharmacokinetic interactions with other medications thatthe patient may be taking.

The rational use of oral combination therapy can temporarily delay theneed for multiple insulin injections, facilitate temporarily themaintenance of low glucose level or low glycosylated hemoglobin (HbA1c)level and help temporarily to prevent vascular complications.

The applicant has surprisingly discovered that DPP-IV inhibitorsespecially LAF237 can be used in combination with Metformin to maintainlow glucose level or low glycosylated hemoglobin (HbA1c) level over anextended period of time. Furthermore the long term treatment with such acombination has significantly less inconvenient than other combinations.

Metformin, i.e. N,N-dimethylimidocarbonimide diamide, is a knowncompound approved by the U.S. Food & Drug Administration for thetherapeutic treatment of diabetes. The compound and its preparation aredisclosed, for example, in U.S. Pat. No. 3,174,901, issued May 23, 1965.It is known that metformin is effective in the treatment of type 2diabetes, otherwise known as non-insulin-dependent diabetes mellitus(NIDDM).

In the present context the term “metformin” is also intended to compriseany salt or crystal form, especially the metformin hydrochloride salt.

The term “DPP-IV inhibitor” is intended to indicate a molecule thatexhibits inhibition of the enzymatic activity of DPP-IV and functionallyrelated enzymes, such as from 1-100% inhibition, and specially preservesthe action of substrate molecules, including but not limited toglucagon-like peptide-1, gastric inhibitory polypeptide, peptidehistidinemethionine, substance P, neuropeptide Y, and other moleculestypically containing alanine or proline residues in the secondaminoterminal position. Treatment with DPP-IV inhibitors prolongs theduration of action of peptide substrates and increases levels of theirintact, undegraded forms leading to a spectrum of biological activitiesrelevant to the disclosed invention.

DPP-IV can be used in the control of glucose metabolism because itssubstrates include the insulinotropic hormones Glucagon like peptide-1(GLP-1) and Gastric inhibitory peptide (GIP). GLP-1 and GIP are activeonly in their intact forms; removal of their two N-terminal amino acidsinactivates them. In vivo administration of synthetic inhibitors ofDPP-IV prevents N-terminal degradation of GLP-1 and GIP, resulting inhigher plasma concentrations of these hormones, increased insulinsecretion and, therefore, improved glucose tolerance. For that purpose,chemical compounds are tested for their ability to inhibit the enzymeactivity of purified CD26/DPP-IV. Briefly, the activity of CD26/DPP-IVis measured in vitro by its ability to cleave the synthetic substrateGly-Pro-p-nitroanilide (Gly-Pro-pNA). Cleavage of Gly-Pro-pNA by DPP-IVliberates the product p-nitroanilide (pNA), whose rate of appearance isdirectly proportional to the enzyme activity. Inhibition of the enzymeactivity by specific enzyme inhibitors slows down the generation of pNA.Stronger interaction between an inhibitor and the enzyme results in aslower rate of generation of pNA. Thus, the degree of inhibition of therate of accumulation of pNA is a direct measure of the strength ofenzyme inhibition. The accumulation of pNA is measured with aspectrophotometer. The inhibition constant, Ki, for each compound isdetermined by incubating fixed amounts of enzyme with several differentconcentrations of inhibitor and substrate.

In the present context “a DPP-IV inhibitor” is also intended to compriseactive metabolites and prodrugs thereof, such as active metabolites andprodrugs of DPP-IV inhibitors. A “metabolite” is an active derivative ofa DPP-IV inhibitor produced when the DPP-IV inhibitor is metabolised. A“prodrug” is a compound that is either metabolised to a DPP-IV inhibitoror is metabolised to the same metabolite(s) as a DPP-IV inhibitor. Inthe present context the term “a DPP-IV inhibitor” is also intended tocomprise pharmaceutical salts thereof.

DPP-IV inhibitors are known in the art. In the following reference ismade to representatives of DPP-IV inhibitors:

DPP-IV inhibitors are in each case generically and specificallydisclosed e.g. in WO 98/19998, DE19616 486 A1, WO 00/34241, WO 95/15309,WO 01/72290, WO01/52825, WO03/002553, WO 9310127, WO 99/61431, WO9925719, WO 9938501, WO 9946272, WO 9967278 and WO 9967279.

Preferred DPP-IV inhibitors are described in the following patentapplications; WO 02053548 especially compounds 1001 to 1293 and examples1 to 124, WO 02067918 especially compounds 1000 to 1278 and 2001 to2159, WO 02066627 especially the described examples, WO 02/068420especially all the compounds specifically listed in the examples I toLXIII and the described corresponding analogues, even preferredcompounds are 2(28), 2(88), 2(119), 2(136) described in the tablereporting IC50, WO 02083128 such as in the claims 1 to 5 especiallycompounds described in examples 1 to 13 and the claims 6 to 10, US2003096846 especially the specifically described compounds, WO2004/037181 especially examples 1 to 33, WO 0168603 especially compoundsof examples 1 to 109, EP1258480 especially compounds of examples 1 to60, WO 0181337 especially examples 1 to 118, WO 02083109 especiallyexamples 1A to 1D, WO 030003250 especially compounds of examples 1 to166, most preferably 1 to 8, WO 03035067 especially the compoundsdescribed in the examples, WO 03/035057 especially the compoundsdescribed in the examples, US2003216450 especially examples 1 to 450, WO99/46272 especially compounds of claims 12, 14, 15 and 17, WO 0197808especially compounds of claim 2, WO 03002553 especially compounds ofexamples 1 to 33, WO 01/34594 especially the compounds described in theexamples 1 to 4, WO 02051836 especially examples 1 to 712, EP1245568especially examples 1 to 7, EP1258476 especially examples 1 to 32, US2003087950 especially the described examples, WO 02/076450 especiallyexamples 1 to 128, WO 03000180 especially examples 1 to 162, WO 03000181especially examples 1 to 66, WO 03004498 especially examples 1 to 33, WO0302942 especially examples 1 to 68, U.S. Pat. No. 6,482,844 especiallythe described examples, WO 0155105 especially the compounds listed inthe examples 1 and 2, WO 0202560 especially examples 1 to 166, WO03004496 especially examples 1 to 103, WO 03/024965 especially examples1 to 54, WO 0303727 especially examples 1 to 209, WO 0368757 especiallyexamples 1 to 88, WO 03074500 especially examples 1 to 72, examples 4.1to 4.23, examples 5.1 to 5.10, examples 6.1 to 6.30, examples 7.1 to7.23, examples 8.1 to 8.10, examples 9.1 to 9.30, WO 02038541 especiallyexamples 1 to 53, WO 02062764 especially examples 1 to 293, preferablythe compound of example 95(2-{{3-(Aminomethyl)-4-butoxy-2-neopentyl-1-oxo-1,2dihydro-6-isoquinolinyl}oxy}acetamide hydrochloride), WO 02308090especially examples 1-1 to 1-109, examples 2-1 to 2-9, example 3,examples 4-1 to 4-19, examples 5-1 to 5-39, examples 6-1 to 6-4,examples 7-1 to 7-10, examples 8-1 to 8-8, examples 7-1 to 7-7 of page90, examples 8-1 to 8-59 of pages 91 to 95, examples 9-1 to 9-33,examples 10-1 to 10-20, US 2003225102 especially compounds 1 to 115,compounds of examples 1 to 121, preferably compounds a) to z), aa) toaz), ba) to bz), ca) to cz) and da) to dk), WO 0214271 especiallyexamples 1 to 320, US 2003096857, U.S. application Ser. No. 09/788,173filed Feb. 16, 2001 (attorney file LA50) especially the describedexamples, WO99/38501 especially the described examples, WO99/46272especially the described examples and DE19616 486 A1 especially val-pyr,val-thiazolidide, isoleucyl-thiazolidide, isoleucyl-pyrrolidide, andfumar salts of isoleucyl-thiazolidide and isoleucyl-pyrrolidide.

Further preferred DPP-IV inhibitors include the specific examplesdisclosed in U.S. Pat. No. 6,124,305 and U.S. Pat. No. 6,107,317,International Patent Applications, Publication Numbers WO 9819998, WO95153 09 and WO 9818763; such as 1[2-[(5eyanopyridin-2-yl)aminoethylamino]acetyl-2-cyano-(S)-pyrrolidine and(2S)-1-[(2S)-2 amino-3,3-dimethylbutanoyl]-2-pyrrolidinecarbonitrile.

In a further preferred embodiment, the DPP-IV inhibitor is aN-peptidyl-O-aroyl hydroxylamine or a pharmaceutically acceptable saltthereof. Aroyl is, for example, naphthylcarbonyl; or benzoyl which isunsubstituted or mono- or disubstituted, for example, by lower alkoxy,lower alkyl, halogen or, preferably, nitro. The peptidyl moietycomprises preferably two α-amino acids, e.g. glycine, alanine, leucine,phenylalanine, lysine or proline, of which the one attached directly tothe hydroxylamine nitrogen atom is preferably proline. In each case inparticular in the compound claims and the final products of the workingexamples, the subject matter of the final products, the pharmaceuticalpreparations and the claims are hereby incorporated into the presentapplication by reference to these publications.

WO 9819998 discloses N—(N′-substituted glycyl)-2-cyano pyrrolidines, inparticular1-[2-[5-Cyanopyridin-2-yl]amino]-ethylamino]acetyl-2-cyano-(S)-pyrrolidine.

Preferred compounds described in WO03/002553 are listed on pages 9 to 11and are incorporated into the present application by reference.

DE19616 486 A1 discloses val-pyr, val-thiazolidide,isoleucyl-thiazolidide, isoleucyl-pyrrolidide, and fumar salts ofisoleucyl-thiazolidide and isoleucyl-pyrrolidide.

WO 0034241 and U.S. Pat. No. 6,110,949 disclose N-substitutedadamantyl-amino-acetyl-2-cyano pyrrolidines and W (substitutedglycyl)-4-cyano pyrrolidines respectively. DPP-IV inhibitors of interestare specially those cited in claims 1 to 4.

WO 9515309 discloses amino acid 2-cyanopyrrolidine amides as inhibitorsof DPP-IV and WO 9529691 discloses peptidyl derivates of diesters ofalpha-aminoalkylphosphonic acids, particularly those with proline orrelated structures. DPP-IV inhibitors of interest are specially thosecited in Table 1 to 8.

In WO 01/72290 DPP-IV inhibitors of interest are specially those citedin example 1 and claims 1, 4, and 6.

WO01/52825 specially discloses(S)-1-{2-[5-cyanopyridin-2-yl)amino]ethyl-aminoacetyl)-2-cyano-pyrrolidineor (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine(LAF237).

WO 9310127 discloses proline boronic esters useful as DPP-IV inhibitors.DPP-IV inhibitors of interest are specially those cited in examples 1 to19.

Published patent application WO 9925719 discloses sulphostin, a DPP-IVinhibitor prepared by culturing a Streptomyces microorganism.

WO 9938501 discloses N-substituted 4- to 8-membered heterocyclic rings.DPP-IV inhibitors of interest are specially those cited in claims 15 to20.

WO 9946272 discloses phosphoric compounds as inhibitors of DPP-IV.DPP-IV inhibitors of interest are specially those cited in claims 1 to23.

Other preferred DPP-IV inhibitors are the compounds of formula I, II orIII disclosed in the patent application WO 03/057200 on page 14 to 27.Most preferred DPP-IV inhibitors are the compounds specificallydescribed on pages 28 and 29.

Published patent applications WO 9967278 and WO 9967279 disclose DPP-IVprodrugs and inhibitors of the form A-B-C where C is either a stable orunstable inhibitor of DPP-IV.

Preferably, the N-peptidyl-O-aroyl hydroxylamine is a compound offormula VII

whereinj is 0, 1 or 2;Rε₁ represents the side chain of a natural amino acid; andRε₂ represents lower alkoxy, lower alkyl, halogen or nitro;or a pharmaceutically acceptable salt thereof.

In a very preferred embodiment of the invention, the N-peptidyl-O-aroylhydroxylamine is a compound of formula VIIa

or a pharmaceutically acceptable salt thereof.

N-Peptidyl-O-aroyl hydroxylamines, e.g. of formula VII or VIIa, andtheir preparation are described by H. U. Demuth et al. in J. EnzymeInhibition 1988, Vol. 2, pages 129-142, especially on pages 130-132.

Preferred DPP-IV inhibitors are those described by Mona Patel and col.(Expert Opinion Investig Drugs. 2003 April; 12(4):623-33) on theparagraph 5, especially P32/98, K-364, FE-999011, BDPX, NVP-DDP-728 andothers, which publication is hereby incorporated by reference especiallythe described DPP-IV inhibitors.

Another preferred DPP-IV inhibitor is the No. 815541 (T 6666) fromTanabe.

Preferred DPP-IV inhibitors are also described in the patentapplications WO 02/083128, especially the compounds described in theexamples 1 to 13, U.S. Pat. No. 6,395,767 examples 1 to 109 and WO03/033671 all the specifically described compounds e.g. compounds 1 to393, compounds of pages 67-70.

FE-999011 is described in the patent application WO 95/15309 page 14, ascompound No. 18.

Another preferred inhibitor is the compound BMS-477118 disclosed in WO2001068603 or U.S. Pat. No. 6,395,767 (compound of example 60) alsoknown as is(1S,3S,5S)-2-[(2S)-2-amino-2-(3-hydroxytricyclo[3.3.1.1^(3.7)]dec-1-yl)-1-oxoethyl]-2-azabicyclo[3.1.0]hexane-3-carbonitrile,benzoate (1:1) as depicted in Formula M of the patent application WO2004/052850 on page 2, and the corresponding free base,(1S,3S,5S)-2-[(2S)-2-amino-2-(3-hydroxy-tricyclo[3.3.1.1^(3.7)]dec-1-yl)-1-oxoethyl]-2-azabicyclo-[3.1.0]hexane-3-carbonitrile(M′) and its monohydrate (M″) as depicted in Formula M of the patentapplication WO 2004/052850 on page 3. The compound BMS-477118 is alsoknown as saxagliptin.

Another preferred inhibitor is the compound GSK23A disclosed in WO03/002531 (example 9) also known as(2S,4S)-1-((2R)-2-Amino-3-[(4-methoxybenzyl)sulfonyl]-3-methylbutanoyl)-4-fluoropyrrolidine-2-carbonitrilehydrochloride.

P32/98 (CAS number: 251572-86-8) also known as3-[(2S,3S)-2-amino-3-methyl-1-oxopentyl]thiazolidine can be used as3-[(2S,3S)-2-amino-3-methyl-1-oxopentyl]thiazolidine and(2E)-2-butenedioate (2:1) mixture and is described in WO 99/61431 andthe below formula,

is described in WO 99/61431 and also in Diabetes 1998, 47, 1253-1258, inthe name of Probiodrug, as well as the compound P93/01 described by thesame company.

Other very preferred DPP-IV inhibitors are the compounds disclosed inthe patent application WO 02/083128 such as in the claims 1 to 5. Mostpreferred DPP-IV inhibitors are the compounds specifically described bythe examples 1 to 13 and the claims 6 to 10.

Other very preferred DPP-IV inhibitors are the compounds disclosed ByBristol-Myers Squibb such as Saxagliptin (BMS477118).

Other very preferred DPP-IV inhibitors of the invention are described inthe International patent application WO 02/076450 (especially theexamples 1 to 128) and by Wallace T. Ashton (Bioorganic & MedicinalChemistry Letters 14 (2004) 859-863) especially the compound 1 and thecompounds listed in the tables 1 and 2. The preferred compound is thecompound 21e (table 1) of formula:

Other preferred DPP-IV inhibitors are described in the patentapplications WO 2004/037169 especially those described in the examples 1to 48 and WO 02/062764 especially the described examples 1 to 293, evenpreferred are the compounds3-(aminomethyl)-2-isobuthyl-1-oxo-4-phenyl-1,2-dihydro-6-isoquinolinecarboxamideand2-{[3-(aminomethyl)-2-isobuthyl-4-phenyl-1-oxo-1,2-dihydro-6-isoquinolyl]oxy}acetamidedescribed on page 7 and also in the patent application WO2004/024184especially in the reference examples 1 to 4.

Other preferred DPP-IV inhibitors are described in the patentapplication WO 03/004498 especially examples 1 to 33 and most preferablythe compound of the formula

described by the example 7 and also known as MK-0431.

In each case in particular in the compound claims and the final productsof the working examples, the subject matter of the final products, thepharmaceutical preparations and the claims are hereby incorporated intothe present application by reference to these publications.

Preferred DPP-IV inhibitors are also described in the patent applicationWO 2004/037181 especially examples 1 to 33 and most preferably thecompounds described in the claims 3 to 5.

Preferred DPP-IV inhibitors are N-substitutedadamantyl-amino-acetyl-2-cyano pyrrolidines, N(substitutedglycyl)-4-cyano pyrrolidines, N-(N′-substitutedglycyl)-2-cyanopyrrolidines, N-aminoacyl thiazolidines, N-aminoacylpyrrolidines, L-allo-isoleucyl thiazolidine, L-threo-isoleucylpyrrolidine, and L-allo-isoleucyl pyrrolidine,1-[2-[(5-cyanopyridin-2-yl)amino]ethylamino]acetyl-2-cyano-(S)-pyrrolidine,MK-431 and pharmaceutical salts thereof.

Most preferred DPP-IV inhibitors are selected from[S]-1-[2-(5-cyano-2-pyridinylamino)ethylamino]acetyl-2-pyrrolidinecarbonitrile monohydrochloride,(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine andL-threo-isoleucyl thiazolidine (compound code according to Probiodrug:P32/98 as described above), MK-0431,3-(aminomethyl)-2-isobuthyl-1-oxo-4-phenyl-1,2-dihydro-6-isoquinolinecarboxamideand2-{[3-(aminomethyl)-2-isobuthyl-4-phenyl-1-oxo-1,2-dihydro-6-isoquinolyl]oxy}acetamideand optionally pharmaceutical salts thereof.

[S]-1-[2-(5-cyano-2-pyridinylamino)ethylamino]acetyl-2-pyrrolidinecarbonitrile monohydrochloride and(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine arespecifically disclosed in Example 3 of WO 98/19998 and Example 1 of WO00/34241, respectively. The DPP-IV inhibitor P32/98 (see above) isspecifically described in Diabetes 1998, 47, 1253-1258.[S]-1-[2-(5-cyano-2-pyridinylamino)ethylamino]acetyl-2-pyrrolidinecarbonitrile monohydrochloride and(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine can beformulated as described on page 20 of WO 98/19998 or in WO 00/34241.

Especially preferred are1-{2-[(5-cyanopyridin-2-yl)amino]ethylamino}acetyl-2-(S)-cyano-pyrrolidine(also named[S]-1-[2-(5-cyano-2-pyridinylamino)ethylamino]acetyl-2-pyrrolidinecarbonitrile monohydrochloride), of formula:

especially the dihydrochloride and monohydrochloride form thereof,pyrrolidine, 1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-, (S) (alsonamed (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine,LAF237 or vildagliptin) of formula

and L-threo-isoleucyl thiazolidine (compound code according toProbiodrug: P32/98 as described above), MK-0431, GSK23A, saxagliptin,3-(aminomethyl)-2-isobuthyl-1-oxo-4-phenyl-1,2-dihydro-6-isoquinolinecarboxamideand2-{[3-(aminomethyl)-2-isobuthyl-4-phenyl-1-oxo-1,2-dihydro-6-isoquinolyl]oxy}acetamideand optionally in any case pharmaceutical salts thereof.

DPP728 and LAF237 are specifically disclosed in Example 3 of WO 98/19998and Example 1 of WO 00/34241, respectively. The DPP-IV inhibitor P32/98(see above) is specifically described in Diabetes 1998, 47, 1253-1258.DPP728 and LAF237 can be formulated as described on page 20 of WO98/19998 or in WO 00/34241, or in the International Patent ApplicationNo. EP2005/000400 (application number).

Any of the substances disclosed in the above mentioned patent documentsor scientific publications, hereby included by reference, are consideredpotentially useful as DPP-IV inhibitors to be used in carrying out thepresent invention.

DPP-IV inhibitor to be used alone according to the present invention canbe used in association with a carrier.

A carrier in the instant context is a tool (natural, synthetic,peptidic, non-peptidic) for example a protein which transports specificsubstances through the cell membrane in which it is embedded and intothe cell. Different carriers (natural, synthetic, peptidic,non-peptidic) are required to transport different substances, as eachone is designed to recognize only one substance, or group of similarsubstances.

Any means of detection known by the person skilled in the art can beused to detect the association of the DPP-IV with a carrier, forexample, by labelling the carrier.

The DPP-1V inhibitor can be a peptidic or, preferably, non-peptidic one.

Most preferred are orally active DPP-IV inhibitors and pharmaceuticalsalts thereof.

The active ingredients (metformin or DPP-1V inhibitors) orpharmaceutically acceptable salts thereof according to the presentinvention may also be used in form of a solvate, such as a hydrate orincluding other solvents, used for crystallization.

It has now been surprisingly found that DPP-IV inhibitors especiallyLAF237 can be used in combination with Metformin to maintain lower bloodglucose levels and/or lower glycosylated hemoglobin (HbA1c) level overan extended period of time.

Thus in a first embodiment, this invention provides a method forcontrolling glucose levels over an extended period of time comprisingadministering a therapeutically effective amount of metformin and aDPP-IV inhibitor to a patient in need thereof.

This invention further provides a method for controlling glycosylatedhemoglobin (HbA1c) levels over an extended period of time comprisingadministering a therapeutically effective amount of metformin and aDPP-IV inhibitor to a patient in need thereof.

Or the use of metformin in combination with a DPP-IV inhibitor for themanufacture of a medicament for controlling the blood HbA1c or glucoselevel over an extended period of time in a patient in need thereof.

The invention also relates to a method for maintaining glucose orglycosylated hemoglobin (HbA1c) levels over an extended period of timecomprising administering a therapeutically effective amount of metforminand a DPP-IV inhibitor to a patient in need thereof.

Preferably the DPP-IV inhibitor is(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine (LAF237or vildagliptin) of formula (I)

or pharmaceutically acceptable salt thereof.

In the present context the terms“(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine” or“LAF237” or “vildagliptin” is also intended to comprise any salt orcrystal form thereof.

Preferably the treated patient is suffering from hyperglycemia. Mostpreferably the patient is suffering from a disease selected fromdiabetes mellitus, type I or insulin-dependent diabetes mellitus (IDDM),type II or non-insulin-dependent diabetes mellitus (NIDDM), type Ainsulin resistance, IGM, IFG or IGT. In a preferred embodiment thepatient is suffering from type II diabetes or IGT.

In a most preferred embodiment the DPP-IV inhibitor is added to thestandard diabetes treatment in patients whose disease was not adequatelycontrolled by metformin alone.

The present methods or uses are particularly useful for the preventionor delay of progression of conditions associated with type II diabetesor IGT, particularly cardiovascular and microvascular conditions.

The invention furthermore relates to the use of metformin in combinationwith a DPP-IV inhibitor for the manufacture of a medicament to controlthe blood HbA1c or glucose level over an extended period of time in thetreated patient, particularly in a patient (e.g. type II diabeticpatient) not adequately controlled by metformin alone.

Preferably the invention relates to the use of metformin in combinationwith a DPP-IV inhibitor for the manufacture of a medicament to controlthe blood HbA1c or glucose level over an extended period of time in apatient (e.g. type II diabetic patient) not adequately controlled bymetformin alone.

The term “control” means that the glucose level or the HbA1c level inthe blood does not increase more than 8%, preferably less than 5%, morepreferably less than 3%, even more preferably less than 2%, mostpreferably less than 1.5% or 1.2% from baseline lower glucose level orlower HbA1c level reached with the used combination therapy (seeexamples 1 or 2).

The term “over an extended period of time” means at least 10 months,preferably at least 12 months, or at least 18 months.

Furthermore as used herein, “a daily dose” means the dose given within a24-hour period.

The term “prevention” means prophylactic administration of thecombination to healthy patients to prevent the outbreak of theconditions mentioned herein. Moreover, the term “prevention” meansprophylactic administration of such combination to patients being in apre-stage of the conditions, to be treated.

The term “delay of progression” used herein means administration of thecombination, such as a combined preparation or pharmaceuticalcomposition, to patients being in a pre-stage of the condition to betreated in which patients a pre-form of the corresponding condition isdiagnosed.

By the term “treatment” is understood the management and care of apatient for the purpose of combating the disease, condition, ordisorder.

As used herein, the term “patient” refers to an animal who is sufferingfrom hyperglycemia or diabetes or IGM. The preferred animal is a mammal,such as dogs, cats, horses, cows and humans. It is preferred that thepatient is a human.

In this field the preferred patient population age is from 45 yearsonwards, most preferred from 60 years onwards.

The person skilled in the pertinent art is fully enabled to select arelevant test model and protocols to prove the beneficial effects of theinvention.

Monitoring of glycemic status, as performed by patients and health careproviders, is well known in the art such as reported in Diabetes Care“Tests of Glycemia in Diabetes—American Diabetes Association”2003 26:S106-108 and described below. This publication is hereby incorporated byreference in their entirety.

The American Diabetes Association's technical review should be consultedfor further information (e.g. Goldstein D E, Little R R, Lorenz R A,Malone J I, Nathan D, Peterson C M: Tests of glycemia in diabetes(Technical Review). Diabetes Care 18:896-909, 1995).

Within only a few years, self-monitoring of blood glucose (SMBG) bypatients has revolutionized management of diabetes. Using SMBG, patientswith diabetes can work to achieve and maintain specific glycemic goals.

The subject of SMBG has been addressed extensively by two AmericanDiabetes Association Consensus Conferences, which provide acomprehensive review of the subject (American Diabetes Association:Self-monitoring of blood glucose (Consensus Statement). Diabetes Care17:81-86, 1994—and—American Diabetes Association: Self-monitoring ofblood glucose (Consensus Statement). Diabetes Care 10:93-99, 1987)

SMBG has supplanted urine glucose testing for most patients. Urineglucose testing by patients in the home setting consists ofsemiquantitative measurements based on single voidings or, less often,by more quantitative “blocks” collected over 4-24 h. The rationale isthat urinary glucose values reflect mean blood glucose during the periodof urine collection.

Blood and urine glucose testing and urine ketone testing provide usefulinformation for day-to-day management of diabetes.

However, these tests cannot provide the patient and health care teamwith a quantitative and reliable measure of glycemia over an extendedperiod of time. Measurements of glycated proteins, primarily hemoglobinand serum proteins, have added a new dimension to assessment ofglycemia. With a single measurement, each of these tests can quantifyaverage glycemia over weeks and months, thereby complementing day-to-daytesting.

Glycated Hemoglobin (GHb) Testing:

GHb, also referred to as glycohemoglobin, glycosylated hemoglobin,HbA_(1c), or HbA₁, is a term used to describe a series of stable minorhemoglobin components formed slowly and nonenzymatically from hemoglobinand glucose. The rate of formation of GHb is directly proportional tothe ambient glucose concentration. Since erythrocytes are freelypermeable to glucose, the level of GHb in a blood sample provides aglycemic history of the previous 120 days, the average erythrocyte lifespan. GHb most accurately reflects the previous 2-3 months of glycemiccontrol.

Many different types of GHb assay methods are available to the routineclinical laboratory e.g. HbA_(1c) can be measured by High PerformanceLiquid Chromatography (HPLC) using the ion-exchange method on a Bio-RadDiamat analyzer. A back-up affinity method are used if hemoglobinvariants or hemoglobin degradation peaks are observed.

Methods differ considerably with respect to the glycated componentsmeasured, interferences, and nondiabetic range. Glycated hemoglobin isoften reported as hemoglobin A_(1c). HbA_(1c) has become the preferredstandard for assessing glycemic control. In referring to this test, theterm “A1C test” will be used.

A1C testing should be performed routinely in all patients with diabetes,first to document the degree of glycemic control at initial assessment,then as part of continuing-care. Since the A1C test reflects a meanglycemia over the preceding 2-3 months, measurement approximately every3 months is required to determine whether a patient's metabolic controlhas reached and been maintained within the target range.

The A1C test has been shown to predict the risk for the development ofmany of the chronic complications in diabetes, analogous to usingcholesterol determinations to predict the risk for development ofcardiovascular disease.

Glycated Serum Protein (GSP)

Because the turnover of human serum albumin is much shorter (half-lifeof 14-20 days) than that of hemoglobin (erythrocyte life span of 120days), the degree of glycation of serum proteins (mostly albumin)provides an index of glycemia over a shorter period of time than doesglycation of hemoglobin. Measurements of total GSP and glycated serumalbumin (GSA) correlate well with one another and with measurements ofglycated hemoglobin (A1C test). In situations where the A1C test cannotbe measured or may not be useful (e.g., hemolytic anemias), the GSPassay may be of value in the assessment of the treatment regimen.Several methods have been described that quantify either total GSP ortotal GSA. One of the most widely used is called the fructosamine assay.Values for GSP vary with changes in the synthesis or clearance of serumproteins that can occur with acute systemic illness or with liverdisease. In addition, there is continuing debate as to whetherfructosamine assays should be corrected for serum protein or serumalbumin concentrations.

A single measurement of GSP provides an index of glycemic status overthe preceding 1-2 weeks, while a single A1C test provides an index ofglycemic status over a considerably longer period of time, 2-3 months.

Measurement of GSP, regardless of the specific assay method, should notbe considered equivalent to the A1C test, since it only indicatesglycemic control over a short period of time. Therefore, GSP assayswould have to be performed on a monthly basis to gather the sameinformation as measured by the A1C test three to four times a year.Unlike the A1C test, GSP has not yet been shown to be related to therisk of the development or progression of chronic complications ofdiabetes.

Thus regular review of the glucose level or glycated haemoglobin (HbA1c)level progression should be checked every 3-6 months, according to thecurrent guidelines for treatment of diabetes especially type 2 diabetesmellitus.

The glucose level progression checks (e.g. GSP assay, A1C, insulin) arewell known by the physicians and reported in the art e.g. by theAmerican Diabetes Association.

The applicant has surprisingly discovered that regular review of theglucose level or glycated haemoglobin (HbA1c) level progression checkscan be reduced from 2 to 3 times annually to only one check annually orone every 18 months. Thus the costs that diabetic patients bear aredecreased.

Therefore in a further embodiment, the present invention relates to amethod for monitoring the glucose level in an patient comprisingtreating the patient with a pharmaceutically effective amount ofmetformin or a pharmaceutically acceptable salt thereof in combinationwith a DPP-IV inhibitor or a pharmaceutically acceptable salt thereofand checking the patient's glucose level on an annual basis (i.e. once ayear) or once every 18 months.

In a preferred aspect, the present invention relates to a method formonitoring the glycated haemoglobin level in an patient comprisingtreating the patient with a pharmaceutically effective amount ofmetformin or a pharmaceutically acceptable salt thereof in combinationwith a DPP-IV inhibitor or a pharmaceutically acceptable salt thereofand checking the patient's glycated haemoglobin level on an annual basisor once every 18 months.

Method of monitoring as described above, wherein the glucose progressionchecks, the glycated haemoglobin level checks or the A1C test have to beassessed by the physician only on an annual basis or once every 18months.

The glucose progression checks can be performed e.g. by A1C tests, GSPassays, etc.

Method of monitoring as described above, wherein the progression checksof patient's glucose level or glycated haemoglobin level e.g. the A1Ctest, have to be carried out only on an annual basis or once every 18months.

Method of monitoring as described above, wherein the patient is reminded(e.g. via mail or e-mail) to perform a glucose progression check or aglycated haemoglobin level check e.g. the A1C test the A1C test only onan annual basis or once every 18 months.

In another embodiment, the present invention relates to a method foradjusting therapy in an patient comprising treating the patient with apharmaceutically effective amount of metformin or a pharmaceuticallyacceptable salt thereof in combination with a DPP-IV inhibitor or apharmaceutically acceptable salt thereof; and changing a treatmentregimen in said patient, based on an annual progression check ofpatient's glucose level(s) or glycated haemoglobin level(s) e.g, annualA1C test.

In the present application, the treatment regimen or therapy isadjusted/changed only if necessary, based on the result of the annual(or every 18 months) progression checks.

The invention also relates to the use of metformin in combination with aDPP-IV inhibitor for the manufacture of a medicament for the treatmentof hyperglycemia, preferably type 2 diabetes, wherein the treatmentregimen in said patient is changed or adapted based, if necessary, on anannual progression check of patient's glucose level or glycatedhaemoglobin level e.g. annual A1C test.

In a third embodiment, the present invention relates to a method foradjusting therapy in an patient treated with metformin in combinationwith a DPP-IV inhibitor wherein the physician reevaluates and ifnecessary changes the treatment regimen in said treated patient, basedon an annual progression check of patient's glucose level or annual A1Ctest, or once every 18 months. Or to the use of metformin in combinationwith a DPP-IV inhibitor for the manufacture of a medicament for thetreatment of hyperglycemia, preferably type 2 diabetes, wherein thephysician reevaluates and if necessary changes the treatment regimen insaid treated patient, based on an annual progression check of patient'sglucose level or glycated haemoglobin level e.g. annual A1C test (oronce every 18 months).

The invention in a further aspect relates to the use of a A1C test tomonitor the glycated haemoglobin (HbA1c) level in a blood sample,wherein said blood sample is collected from a patient treated withmetformin in combination with a DPP-IV inhibitor, and wherein the A1Ctest is performed on an annual basis or once every 18 months.

The invention in a further aspect relates to a method for the treatmentor prevention of type 2 diabetes, comprising administering daily, atherapeutically effective amount of metformin, preferably 1500 to 2000mg of metformin or a pharmaceutically acceptable salt thereof and 50 mgof (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine or apharmaceutically acceptable salt thereof to a patient in need thereof.

The invention also relates to a treatment regimen, for the treatment oftype 2 diabetes wherein,

-   -   i) 50 mg of        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        is to be administered in combination to metformin, preferably        1500 to 2000 mg of metformin, daily, preferably for at least a        period of 12 months to a patient in need thereof,    -   ii) the treatment regimen of metformin and        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        in said patient, being not modified before the end of a 12 month        period.

In the above described treatment regimen, the term “daily”, applies tometformin and(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine(vildagliptin).

The invention also relates to a treatment regimen, for the treatment oftype 2 diabetes wherein,

-   -   i) an effective amount of metformin, preferably 1500 to 2000 mg        of metformin is to be administered daily, as the starting point        of the treatment for a period of time,    -   ii) once administration of metformin does not stabilize the        glucose level or glycated haemoglobin level anymore, 50 mg of        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        is to be administered (daily) in combination to metformin        (daily) (preferably at an unchanged dosage, preferably 1500 to        2000 mg of metformin), daily, preferably for a period of at        least 12 months,    -   iii) the treatment regimen of metformin and        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        in said patient, being not modified before the end of a 12 month        period.

The invention also relates to the use of metformin in combination with(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine in themanufacture of a medicament for the treatment of type 2 diabeteswherein, 50 mg of(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine is to beadministered in combination to metformin, preferably 1500 to 2000 mg ofmetformin, daily, to a patient in need thereof.

The invention also relates to the use of metformin in combination with(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine in themanufacture of a medicament for the treatment of type 2 diabeteswherein,

-   -   i) 50 mg of        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        is to be administered in combination to metformin, preferably        1500 to 2000 mg of metformin, daily, preferably for a period of        at least 12 months to a patient in need thereof,    -   ii) the treatment regimen of metformin and        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        in said patient, being not modified before the end of a 12 month        period.

The invention also relates to the use of metformin in combination with(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine in themanufacture of a medicament for the treatment of type 2 diabeteswherein,

-   -   i) an effective amount of metformin is to be administered as the        starting point of the treatment for a period of time,    -   ii) once administration of metformin does not stabilize the        glucose level or glycated haemoglobin level anymore, 50 mg of        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        is to be administered in combination to metformin, preferably        1500 to 2000 mg of metformin, daily, preferably for a period of        at least 12 months,    -   iii) the treatment regimen of metformin and        (S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine        in said patient, being not modified before the end of a 12 month        period.

Preferably the treated patient in the above described methods or uses,is suffering from hyperglycemia. Most preferably the patient sufferingfrom hyperglycemia, is suffering from a disease selected from diabetesmellitus, type I or insulin-dependent diabetes mellitus (IDDM), type IIor non-insulin-dependent diabetes mellitus (NIDDM), type A insulinresistance, IGM, IFG or IGT. In a preferred embodiment the patient issuffering from type II diabetes or IGT. In another preferred embodimentthe treated patient is a patient whose disease was not adequatelycontrolled by metformin alone.

Use, method or treatment regimen according to the present invention,wherein a progression check of patient's glucose level or glycatedhaemoglobin level e.g. the A1C test, is carried out on an annual basisor once every 18 months.

Use, method or treatment regimen according to the present invention,wherein 1500 to 2000 mg of metformin or a pharmaceutically acceptablesalt thereof in combination with 50 mg of(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine or apharmaceutically acceptable salt thereof, are administered daily to apatient in need thereof.

The structure of the active agents identified by code nos., generic ortrade names may be taken from the actual edition of the standardcompendium “The Merck Index” or from databases, e.g. PatentsInternational (e.g. IMS World Publications). The corresponding contentthereof is hereby incorporated by reference. Any person skilled in theart is fully enabled to identify the active agents and, based on thesereferences, likewise enabled to manufacture and test the pharmaceuticalindications and properties in standard test models, both in vitro and invivo.

The herein described pharmaceutical preparations are for enteral, suchas oral, and also rectal or parenteral, administration to homeotherms,with the preparations comprising the pharmacological active compoundeither alone or together with customary pharmaceutical auxiliarysubstances. For example, the pharmaceutical preparations consist of fromabout 0.1% to 90%, preferably of from about 1% to about 80%, of theactive compound. Pharmaceutical preparations for enteral or parenteral,and also for ocular, administration are, for example, in unit doseforms, such as coated tablets, tablets, capsules or suppositories andalso ampoules. These are prepared in a manner that is known per se, forexample using conventional mixing, granulation, coating, solubulizing orlyophilising processes. Thus, pharmaceutical preparations for oral usecan be obtained by combining the active compound with solid excipients,if desired granulating a mixture which has been obtained, and, ifrequired or necessary, processing the mixture or granulate into tabletsor coated tablet cores after having added suitable auxiliary substances.

The dosage of the active compound can depend on a variety of factors,such as mode of administration, homeothermic species, age and/orindividual condition.

Preferred dosages, for those active ingredients of the pharmaceuticalcombination according to the present invention that are commerciallyavailable, are especially therapeutically effective commerciallyavailable dosages.

The dosage of the active compound can depend on a variety of factors,such as mode of administration, homeothermic species, age and/orindividual condition.

By the terms “treatment regimen is changed or adapted” or “adjustingtherapy” the person skilled of the art would understand e.g.modification of the dosage of the active ingredients, addition of athird active ingredient especially a hypoglycemic agent such as aglitazone (pioglitazone or rosiglitazone) or insulin, or modification ofthe treatment schedule e.g. by reducing or increasing the administrationof one active ingredient e.g. metformin once every two days.

The corresponding active ingredient or a pharmaceutically acceptablesalt thereof may also be used in form of a hydrate or include othersolvents used for crystallization.

The exact dosage will of course vary depending upon the compoundemployed, mode of administration and treatment desired. The compound maybe administered by any conventional route, non-oral or preferablyorally.

In general, satisfactory results are obtained when DPP-IV inhibitorespecially LAF237 is administered at a daily dosage of from about 0.01to 50 mg/kg, more preferred doses ranged from 0.1 to 50 mg/kg.

For the larger mammals, an indicated total daily dosage is in the rangefrom about 0.01 to 100 mg/kg of the compound, conveniently administeredin divided doses 2 to 4 times a day in unit dosage form containing forexample from about 0.1 to about 50 mg of the compound in sustainedrelease form.

Preferably for the DPP-IV inhibitor especially LAF237 an indicated totaldaily dosage is in the range from between 1 and 500 mg, preferablybetween 10 and 200 mg of active ingredient.

Another preferred DPP-IV inhibitor especially LAF237 daily oral dosageis between 1 and 100 mg preferably between 10 and 100 mg e.g. 10 mg,most preferably between 25 and 100 mg e.g. 25 mg or 30 or 40 or 50, 61,70, 90, 100 mg. The very preferred daily oral dosage of LAF237 isbetween 50 and 100 mg.

Appropriate unit doses for oral administration contain for example about25 to about 100 mg of DPP-IV inhibitor especially LAF237, such aspreferably 25, 50 or 100 mg. Appropriate doses for parenteraladministration contain for example about 1 to about 100 mg of thecompound, e.g. from 10 to 50 mg.

The DPP-IV inhibitor can also be administered every day or only everytwo days, or twice a week.

The preparation of metformin (dimethyldiguanide) and its hydrochloridesalt is state of the art and was disclosed first by Emil A. Werner andJames Bell, J. Chem. Soc. 121, 1922, 1790-1794. In general, satisfactoryresults are obtained when Metformin is administered at a daily dosage offrom about 50 mg to about 3000 mg, preferably from about 500 mg to about2000 mg. Metformin can be administered e.g. in the form as marketed e.g.as 500 mg tablets. If the drug metformin shall be administered in aseparate pharmaceutical composition, it can be administered in the formas it is launched e.g. under the trademark DIABETOSAN™ or GLUCOPHAGE™.If the drug metformin shall be administered in a separate pharmaceuticalcomposition in the form of its hydrochloride salt, the metforminhydrochloride salt can be administered in the form as it is launchede.g. under the trademarks DIABETASE 500™, DIABETASE 850™ or GLUCOPHAGES™. Metformin can also be administered only every two days, or twice aweek.

The compounds may be administered in similar manner to known standardsfor uses in these utilities. The suitable daily dosage for a particularcompound will depend on a number of factors such as its relative potencyof activity. A person skilled in the pertinent art is fully enabled todetermine the therapeutically effective dosage.

The compound of the invention may be administered in free base for or asa pharmaceutically acceptable acid addition or quaternary ammonium salt.Such salts may be prepared in conventional manner and exhibit the sameorder of activity as the free forms. If these compounds have, forexample, at least one basic center, they can form acid addition salts.Corresponding acid addition salts can also be formed having, if desired,an additionally present basic center. The compounds having an acid group(for example COOH) can also form salts with bases. For example, thecompounds to be combined can be present as a sodium salt, as a maleateor as a dihydrochloride. The active ingredient or a pharmaceuticallyacceptable salt thereof may also be used in form of a hydrate or includeother solvents used for crystallization.

The present invention refers to a combination which comprises a DPP-IVinhibitor in free or pharmaceutically acceptable salt form, andmetformin or the pharmaceutically acceptable salt thereof and optionallyat least one pharmaceutically acceptable carrier; wherein the activeingredients can be administered simultaneously or sequentially in anyorder, separately or in a fixed combination (same galenic formulation).

A combined preparation which comprises a DPP-IV inhibitor in free orpharmaceutically acceptable salt form and metformin and optionally atleast one, i.e., one or more, e.g. two, pharmaceutically acceptablecarrier for simultaneous, separate or sequential use is especially a“kit of parts” in the sense that the components, a DPP-IV inhibitor infree or pharmaceutically acceptable salt form and metformin, can bedosed independently or by use of different fixed combinations withdistinguished amounts of the components, i.e. at different time pointsor simultaneously. The parts of the kit of parts can then, e.g., beadministered simultaneously or chronologically staggered, that is atdifferent time points and with equal or different time intervals for anypart of the kit of parts. Preferably, the time intervals are chosen suchthat the effect on the treated disease or condition in the combined useof the parts is larger than the effect which would be obtained by use ofonly any one of the components.

A therapeutically effective amount of each of the components of thecombination of the present invention may be administered simultaneouslyor sequentially and in any order, and the components may be administeredseparately or as a fixed combination. For example, the method oftreatment of the invention may comprise (i) administration of a DPP-IVinhibitor in free or pharmaceutically acceptable salt form and (ii)administration of metformin simultaneously or sequentially in any order,in jointly therapeutically effective amounts, preferably insynergistically effective amounts, e.g. in daily dosages correspondingto the ratios described herein.

The pharmaceutical compositions according to the invention can beprepared in a manner known per se and are those suitable for enteral,such as oral or rectal, and parenteral administration to mammals(warm-blooded animals), including man, comprising a therapeuticallyeffective amount of the pharmacologically active compound, alone or incombination with one or more pharmaceutically acceptable carries,especially suitable for enteral or parenteral application.

To further illustrate the invention, but not by way of limitation, thefollowing clinical study is provided. Further experimental protocols aredescribed in the patent application WO 01/52825 describing combinationscomprising a DPP-IV inhibitor and an antidiabetic compound e.g.metformin.

The invention has been described above by reference to preferredembodiments but, as those skilled in the art will appreciate, manyadditions, omissions and modifications are possible all within the scopeof the claims below.

All patents and literature references cited in this specification arehereby incorporated by reference in their entirety. In case ofinconsistencies, the present description, including the definitions andinterpretations, will prevail.

EXAMPLE 1 Clinical Study

This is a 40-week extension to core study, a 12-week randomized,parallel group, multi-center, placebo-controlled trial in patients withType 2 diabetes who are already receiving metformin at a stable dosageof 1500-3000 mg daily. Patients treated with placebo, LAF237 50 mg OD(omnia die/once a day) in addition to metformin during the core studyand maintained their treatment regimen in the extension. The mainobjective of the 40-week extension study is to assess the safety,tolerability and efficacy of long-term administration of LAF237administered in combination with metformin.

1. Study Objectives: Primary

-   i) To evaluate the effect on HbA_(1c) of additional therapy with    LAF237 in patients with Type 2 diabetes mellitus already receiving    metformin at a dosage of 1500-2000 mg daily.-   ii) To evaluate the safety and tolerability of additional therapy    with LAF237 in patients with Type 2 diabetes mellitus already    receiving metformin at a dosage of 1500-2000 mg daily.

2. Overall Study Design

This randomized, parallel group placebo-controlled trial evaluates theefficacy, safety and tolerability of 52 weeks treatment with LAF237 inpatients with Type 2 diabetes who are already receiving metformin at astable dosage of 1500-2000 mg daily. All patients are randomized toreceive either placebo or LAF237 (50 mg) once daily for 52 weeks inaddition to metformin at an unchanged dosage.

During the 4-week run-in period, all patients receive LAF237 placebotablets and are assessed for inclusion in the study. Patients meetingthe inclusion criteria at the Baseline visit receives randomizedtreatment once daily for 52 weeks. The total study duration for eachpatient is 56 weeks. Throughout the study, patients are required tomaintain their prior diet and exercise habits and to continue to takemetformin at an unchanged dosage.

HbA_(1c) and fasting plasma glucose, insulin, pro-insulin, C-peptide andlipids are measured at various times during the study. Hypoglycemia andother adverse events are be documented, as are laboratory evaluations(including amylase and lipase) and vital signs. In addition, a standardmeal test are carried out at baseline (Visit 3) and again at the end ofthe study.

(i) Study Design

3. Baseline Characteristics of Extension Patient Population

metformin + metformin + LAF237 50 mg placebo N = 42 N = 29 Gender (M/F%) 62/38 76/24 Mean age (years) (SD) 58.4 (9.2)  54.3 (12.2) Mean BMI(kg/m²) (SD) 29.6 (3.7)  29.9 (3.6)  Mean duration of Type 2 5.8 (4.2)4.6 (3.6) diabetes (years) (SD) Mean HbA1c (%) (SD) 7.6 (0.6) 7.8 (0.6)Mean FPG (mmol/L) (SD) 9.6 (1.6) 10.1 (1.8)  Mean metformin dose (mg)1794 (270)  1785 (280)  (SD) Mean duration of metformin 28.7 (24.0) 23.7(25.1) use (months) (SD)

4. Treatments Investigational Therapy and Reference Therapy

For the 4-week run-in period, LAF237 placebo tablets is provided. Duringthe 52 week randomized treatment period, LAF237 and matching placebotablets are dispensed in bottles. Each bottle contains sufficientmedication to provide for treatment according to the study protocol andadditional medication to allow for delayed visits.

Treatment is assigned via a randomization number. At Visit 3 (Baseline)the randomization number is assigned only after completion of thebaseline standard meal test.

Treatment Assignment

After satisfying the Week −4 (Visit 1) inclusion/exclusion criteria,each patient receives a unique subject identification number. Aftermeeting the Baseline (Visit 3) eligibility criteria, each patient israndomized to one of the treatment groups.

Blinding

LAF237 active medication and placebo are blinded by the use of tabletswith identical taste, smell, and appearance.

5. Visit Schedule

Visits are scheduled at Weeks −4, −2, 0 (=Baseline), 1, 2, 4, 8, 12, 14,24, 36 and 52. Deviations of ±3 days are allowed for Visits 1 to 5 and±7 days for Visits 6 to 52. Within each period the original schedule(based on Visit 1 (Week −4) for the run-in period and on Visit 3(Baseline) for the double-blind period) must be restored in case ofdeviation.

All blood samples for laboratory evaluations are drawn between 07.00 hand 10.00 h. Patients are instructed not to eat or drink anything(except water) for approximately 7 hours prior to each scheduledlaboratory evaluation. Study medication should not be taken prior tostudy visits.

Efficacy Assessments

Change in HbA_(1c) from Baseline to week 12 or 52 compared to placebo(i.e. metformin alone). This is measured by using Tosoh ion exchangeHigh Performance Liquid Chromotography (HPLC). Primus Affinity HPLC isused as a back-up method if hemoglobin variants or hemoglobindegradation peaks are observed.

Safety Assessments

Safety assessments consist of monitoring and recording all non-seriousand serious adverse events (SAE), the regular monitoring of hematology,blood chemistry and urinalysis values, regular measurement of vitalsigns, the performance of physical examinations and body weightmeasurements.

Laboratory Evaluations

All laboratory samples are sent to a central laboratory for analysis.

Blood chemistry: Includes albumin, amylase (see note), alkalinephosphatase, bicarbonate, total bilirubin, BUN, C-reactive protein,calcium, chloride, LDL, HDL, total cholesterol, creatinine, CPK (seenote), γ-GT, glucose, LDH, inorganic phosphorus, lipase, potassium,total protein, AST, ALT, sodium, triglycerides, uric acid and VLDL.

6. Statistical Methods Statistical Methods:

The primary aim of the study is to evaluate the effect on HbA_(1c) ofadditional therapy with LAF237 after 52 weeks of double blind treatmentin patients with Type 2 diabetes mellitus already receiving metformin ata dosage of 1500-2000 mg daily. Patients will be randomized to placeboor LAF237 (50 mg) once daily for 52 weeks in addition to metformin at anunchanged dosage.

Populations:

Randomized: all patients who received a randomization number.

Intention to treat (ITT): all randomized patients who received trialmedication and had at least one post-baseline efficacy measurement.

Safety: all randomized patients who received trial medication and had atleast one post-baseline safety measurement.

Completer Population: all ITT patients who complete the study and have avalid HbA_(1c) measurement at Week 52.

Background and demographic characteristics: All demographic andbackground data are summarized by treatment group using contingencytables for the qualitative variables. Mean, standard deviation, median,minimum and maximum will be used for quantitative variables.

Baseline comparability among the treatment groups for demographicvariables (as described above) and baseline efficacy variables(HbA_(1c), fasting plasma glucose (FPG), insulin, pro-insulin,C-peptide, lipids, weight and daily dose of metformin) are examinedusing the Cochran-Mantel-Haenszel test for qualitative variables and anF-test for quantitative variables. (These p-values are provided fordescriptive purposes, and are not to be considered to define any formalbasis for determining factors which should be included in statisticalanalysis models.)

Study medication: Duration on double-blind treatment are summarized bytreatment group for the randomized population. A summary table shows, bytreatment group, what doses of metformin patients were taking when theyentered the study.

Concomitant therapy: Prior and concomitant medications and significantnon-drug therapies (as coded using the WHO dictionary) are summarized bytreatment group.

Efficacy Evaluation Efficacy Analysis

The primary efficacy variable is change from baseline in HbA_(1c) at theend of the study. (This uses the last observation carried forward (LOCF)algorithm for subjects who did not have a Week 12 or 52 HbA_(1c)measurement.)

The null hypotheses to be tested are:

H ₀₁:δ_(LAF50)=δ_(Placebo) and H ₀₂:δ_(LAF100)=δ_(Placebo)

where δ is the change from baseline in the treatment group indicated bythe subscript. An ANCOVA model is fitted including terms for treatment,baseline HbA_(1c), centre and treatment by baseline interaction. Thepossibility of a treatment by centre interaction will be investigated,although the interaction term is not be included in the primary analysismodel. Appropriate linear contrasts are used to test the two nullhypotheses at the 2-sided 0.025 level. Mean change from baseline anddifference between the two groups will be summarized showing p-valuesand confidence intervals.

The primary analysis uses the ITT population and is repeated in thecompleter population.

Figures are produced to show the mean HbA_(1c) against time for eachtreatment group, and the change from baseline in HbA_(1c) at eachtimepoint.

Subgroup Analysis

Summaries of absolute values and changes from baseline in HbA_(1c) arealso presented for the following sub-groups in the ITT (Intent to treat)population:

1) Baseline HbA_(1c) (7.0-8.0%, >8.0-9.5%), 2) BMI (Body mass index)(<30 kg/m², ≧30 kg/m²; evaluated using the Week −4 measurement), 3) Age(<65 years, ≧65 years; evaluated using the Week −4 measurement), 4) Sex,5) Center

Safety Evaluation

The assessment of safety is based mainly on the frequency of adverseevents and on the number of laboratory values that fall outside ofpre-determined ranges. Other safety data (e.g. vital signs) will beconsidered as appropriate.

Laboratory data are summarized by presenting summary statistics of rawdata and change from baseline values (means, medians, standarddeviations, minimum, maximum) and by the flagging of notable values indata listings.

Records of hypoglycemic events are summarized by treatment group, eventtype and plasma glucose equivalent during the randomized treatmentperiod.

Sample Size and Power Considerations

The primary analysis variable is change from baseline in HbA_(1c).Assuming a power of 80%, an overall significance level of 5%, aclinically relevant difference of 0.6% in HbA_(1c), a standard deviationof 0.9% (estimate taken from previous studies) and adjusting formultiple comparisons then 45 completed patients are required pertreatment group. Assuming 10-15% of patients drop out, this implies 52patients should be randomized per group.

Results:

Efficacy result - HbA_(1c) (%) change from baseline at endpoint forExtension ITT population Treatment N LS mean (SE) 95% CI p-value A:metformin + 42 −0.50 (0.14) LAF237 50 mg B: metformin + placebo 29  0.60 (0.17) Difference in mean −1.10 (0.22) (−1.53, −0.67) <0.0001change (A − B) LS = least squares, SE = standard error, CI = confidenceinterval

At study endpoint, the adjusted mean reduction from baseline forHbA_(1c) in the metformin+LAF237 50 mg group was 0.5% (p=0.007), and thedifference in adjusted mean changes between this and theMetformin+placebo group was 1.10% (p<0.0001).

The number (%) of responders, defined as the endpoint HbA_(1c)<7%, was41.7% in the metformin+LAF237 50 mg group compared with 10.7% in themetformin+placebo group.

HbA1c (%) change from baseline at endpoint - by baseline HbA1c categoryfor Extension ITT population (below table) metformin + LAF237 50 mgmetformin + placebo N = 42 N = 29 Subgroup Category n BL mean change(SD) n BL mean change (SD) HbA1c at <7.0% 6 6.92 −0.18 (0.34) 1 6.950.95 (—)   baseline ≧7% and ≦8% 25 7.42 −0.41 (0.56) 17 7.43 0.77(0.70) >8% and ≦9% 10 8.40 −0.62 (1.08) 11 8.39 0.29 (1.43) BL =baseline

Raw Mean (±SE) HbA1c (%) over time (Extension ITT population - belowtable) Number of Mean Standard WEEK patients HbA1c (%) Variation errorTreatment −4 41 7.724390244 0.41339024 0.10041259 Metformin (Met) +LAF237 50 mg −2 42 7.657142857 0.39909408 0.09747943 Met + LAF 50 mg 042 7.583333333 0.32239837 0.08761365 Met + LAF 50 mg 4 42 7.2547619050.30985482 0.08589235 Met + LAF 50 mg 8 42 7.10952381 0.378443670.09492399 Met + LAF 50 mg 12 42 7.05 0.35329268 0.09171549 Met + LAF 50mg 16 42 7.069047619 0.39828688 0.0973808 Met + LAF 50 mg 24 40 7.0550.43279487 0.10401861 Met + LAF 50 mg 36 36 7.083333333 0.510571430.11909047 Met + LAF 50 mg 52 33 7.13030303 0.58280303 0.13289356 Met +LAF 50 mg −4 29 7.937931034 0.41172414 0.11915278 Met + Placebo −2 297.820689655 0.34312808 0.10877501 Met + Placebo 0 29 7.7344827590.34019704 0.10830943 Met + Placebo 4 29 7.589655172 0.270246310.09653413 Met + Placebo 8 29 7.606896552 0.31995074 0.10503706 Met +Placebo 12 29 7.765517241 0.40591133 0.11830867 Met + Placebo 16 287.832142857 0.53041005 0.13763436 Met + Placebo 24 29 7.8965517240.71605911 0.15713591 Met + Placebo 36 28 7.946428571 0.664060850.15400149 Met + Placebo 52 26 8.330769231 1.23661538 0.21808744 Met +Placebo

In this study, HbA1c levels, the primary long-term measure of glycemiccontrol, decreased significantly when LAF237 was added to a patient'scourse of therapy, and this benefit was maintained for one year.Bringing patients to an ideal HbA1c level early in the disease process,and maintaining those levels for as long as possible, is critical intype 2 diabetes, making these findings very unexpected and encouraging.

Patients who were part of the metformin plus LAF237 treatment armsustained an HbA1c level that was an average of 1.1 percent lower thanthe group on metformin plus placebo. Glucose levels measured after 8-12hours of fasting and 1-2 hours after eating a meal were also reduced inpatients taking metformin plus LAF237 versus continued therapy withmetformin alone. The metformin plus LAF237 group maintained lower HbA1clevels for one year. In contrast, researchers saw an increase in HbA1cin the metformin only group during the same period. LAF was found to bewell tolerated with 76.2 and 89.7 percent of patients completing the 52week investigation in the LAF237 plus metformin arm and metformin plusplacebo arms respectively.

EXAMPLE 2

If the lower HbA1c level obtained in a patient treated with one of theherein described combination is 7.04%, and the HbA1c level after 52weeks of treatment with said combination is 7.12%, the HbA1c levelincreased only by 1.13%, which is in line with our very preferredembodiments.

1. A method for controlling glucose levels over an extended period oftime comprising administering a therapeutically effective amount ofmetformin or a pharmaceutically acceptable salt thereof and a DPP-IVinhibitor or a pharmaceutically acceptable salt thereof to a patient inneed thereof.
 2. A method for controlling glycosylated hemoglobin levelsover an extended period of time comprising administering apharmaceutically effective amount of metformin or a pharmaceuticallyacceptable salt thereof and a DPP-IV inhibitor or a pharmaceuticallyacceptable salt thereof to a patient in need thereof.
 3. A method formonitoring the glucose level in an patient comprising treating thepatient with a pharmaceutically effective amount of metformin or apharmaceutically acceptable salt thereof in combination with a DPP-IVinhibitor or a pharmaceutically acceptable salt thereof; and checkingthe patients glucose level on an annual basis or once every 18 months.4. A method for monitoring the glycated haemoglobin level in an patientcomprising treating the patient with a pharmaceutically effective amountof metformin or a pharmaceutically acceptable salt thereof incombination with a DPP-IV inhibitor or a pharmaceutically acceptablesalt thereof; and checking the patient's glycated haemoglobin level onan annual basis or once every 18 months.
 5. A method for adjustingtherapy in an patient treated with metformin or a pharmaceuticallyacceptable salt thereof in combination with a DPP-IV inhibitor or apharmaceutically acceptable salt thereof, wherein the physicianreevaluates and if necessary changes the treatment regimen in saidtreated patient, based on an annual progression check of patient'sglucose level or glycated haemoglobin level.
 6. A method according toclaim 3, wherein the glucose level progression check, the glycatedhaemoglobin level check or the A1C test have to be assessed by thephysician only on an annual basis or once every 18 months.
 7. A methodaccording to claim 3, wherein the progression checks of patients glucoselevel or glycated haemoglobin level, have to be carried out only on anannual basis or once every 18 months.
 8. A method according to claim 3,wherein the patient is reminded to perform a glucose progression checkor a glycated haemoglobin level check, only on an annual basis or onceevery 18 months.
 9. The method according to claim 1 wherein the DPP-IVinhibitor is(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine in freeform or in acid addition salt form.
 10. The method according to claim 1comprising administering a pharmaceutical composition comprisingmetformin or a pharmaceutically acceptable salt thereof and a OPP-IVinhibitor or a pharmaceutically acceptable salt thereof.
 11. The methodaccording to claim 1 wherein 50 mg of(S)-1-[(3-hydroxy-1-adamantyl)amino]acetyl-2-cyano-pyrrolidine or apharmaceutically acceptable salt thereof are administered daily.
 12. Themethod according to claim 1 wherein 1500 to 2000 mg of metformin or apharmaceutically acceptable salt thereof are administered daily.
 13. Themethod according to claim 1 wherein the patient is suffering from adisease selected from diabetes mellitus, insulin-dependent diabetesmellitus, non-insulin-dependent diabetes mellitus, type A insulinresistance, IGM, IFG or IGT.
 14. The method according to claim 1 whereinthe patient selected is a patient whose disease was not adequatelycontrolled by metformin alone.